GW1-2021-05832_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells ������w
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1.Well Contractor Information: .. 4�Q
John W. Huneycutt Ili O �7 2oL� FR.WATERZONES
FRO7f't
TO DESCRIPTION
Well Contractor Name 60 ft- 10 gpm
2465-A Inform-ation P
roce
s
s
ng 16572 fL 20 gpm
NC Well Contractor Certification Number pW R 5ecton 15.OUTER CASiNC for multi-cased wells OR LINER if a licable
FROM TO DIAMETER i THIC 10-% MATERIAL
Derry's Well Drilling, Inc. 0 ft. 180 ft. 161/8 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothetmal closed-loop)
07O177H FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit tl: ft. ft. n
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
'
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft' 3 n• Bent.Chips Gravity
Non-Water Supply Well:
3 ft 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVELPACK(if applicable)
Cl Aquifer StOrB a and Recovery ❑Salinity Barrier FROM TO MATERIAL eMPLACEM[ENT METHOD
g �' ft. fL
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it naeessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color.h;Wness soillrock type,grain slat,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 45 ft. Red Dirt
3/24/21 45 ft. 70 ft. Dirt Rock
4.Date Wells}Completed: Well il?i#
70 ft 185 ft. Blue Rock
5a.Well Location: ft. ft.
Patrick Reardon ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2061 Patriot Woods Dr., Asheboro 27205 Seams: 115', 155'=10g, 165'=20g
ft ft.
Physical Address,City,and Zip 21.REMARKS
Randolph 7742997475
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field.one Iatllong is sufficient)
N W ir,�y (�(/, � 4/1/21
Sign of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or []Temporary Ry signing this form.I hereby certify that the welits)it-as(were)eanetrucied in accordance
with 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or [KIND copy of this record has been provided to the;well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under r21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Nor multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTTICTiONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths tfdii ferem(example-3@200 and 1 100') construction to the following:
10.Static water level below top of casing: 26 (ft) Division of Water Resources,information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter. 6 (in.) 24b.For infection Wells ONLY: in addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method Rotary construction to the following: f
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) 30 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this forme within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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